APPLICATION FORM 2010

for International Students

1. PeRsONAL DeTAILs Enter your full name in this section as shown on your passport or birth certificate. You should attach an original or witnessed copy of your birth certificate or a witnessed copy of the personal details page from your passport. Student Number (Office use only) Ethnic Origin(s) (This information is used for New Zealand Ministry of Education statistical
purposes or University purposes only)

Please indicate the group(s) with which you identify.

(Tick one or more circles)

121. British/Irish 122. Dutch 123. Greek Title (Tick one) Mr Miss Ms Mrs Dr 124. Polish 125. South Slav 126. Italian 127. German 128. Australian Given Name(s) 129. Other European (please specify) Other (please specify) Family Name

311. Samoan Preferred Given Name 331. Tongan 361. Fijian 371. Other Pacific Peoples (please specify) Previous Name(s) Original or witnessed evidence of name change must be attached.

411. Filipino 412. Cambodian

Date of Birth 19
Day Month Year

413. Vietnamese 414. Other Southeast Asian (please specify)

Gender Male Female

421. Chinese 431. Indian 441. Sri Lankan 442. Japanese 443. Korean 444. Other Asian (please specify)

New Zealand National Student Number (NSN) If you have a NSN or NZQA number, please write it here.

Nationality (List countries where you hold Citizenship/Residence) Citizenship

511. Middle Eastern 521. Latin American 531. African

Residence Visa

611. Other (please specify)

Study Location Will you be resident in New Zealand for the duration of your study? Yes No

If you identify with more than one ethnic group, please list in order of your preference (e.g. 127, 121).

Disabilities (The completion of this section is not compulsory) Do you have an impairment, disability or long-term medical condition? Yes No

State/Province Postcode/zipcode Country Telephone Facsimile ( ( ) )

If yes, how would you describe your impairment, disability or medical condition? Please tick one or more of the following: 1. Deaf 2. Hearing 3. Blind 4. Vision 5. Specific learning 6. Medical 7. Head injury 8. Mental Health 9. Mobility 10. Speech 11. Temporary impairment 12. Other (please specify)

Permanent home address valid from to

Day Month Year Day Month Year

Correspondence Address (If different from Permanent Home Address. This is the primary
address the University will use to contact you.)

Does your impairment, disability or medical condition affect your study? Yes No

Address

Emergency Contact Person (Next of Kin) Name Relationship Email address Telephone Country of Residence Permanent Home Address Email Address Mobile Telephone Address ( ) ( ) State/Province Postcode/zipcode Country Telephone Mobile Telephone Facsimile ( ( ( ) ) )

Correspondence address valid from to

Day Month Year Day Month Year

Preferred Method of Contact (Please indicate how you would like the University to
contact you about enrolment matters. Tick one circle only.)

Email

Post

2. APPOINTMeNT OF AgeNT (to be completed by the applicant) Are you using a University of Otago authorised agent to handle your application?: If yes, I authorise the University of Otago to release personal information to the following agent: Yes No

3. PROPOseD sTuDy I plan to begin coursework study in: Semester 1 (Feb - June
Year

Semester 2 (July - Nov

Year

Summer School (Jan - Feb

Year

Thesis Commencement Date If you are applying for a thesis-only programme, please supply the approximate date on which you expect to begin your thesis research:

Intended Qualification The qualification I am applying for is: Name of Programme (eg Bachelor of Commerce, Master of Arts) 1. 2. Intended Papers (Not applicable to research-only students) If you know which papers you wish to take in 2010 please enter them below. To complete this section, you will need to refer to the Guide to Enrolment 2010 or the Universitys website, www.otago.ac.nz/subjects Paper Code
EXAMPLE

Major Subject (eg Finance, English)

Teaching Period S1

Paper Name Statistical Methods

STAT 110

4. eNgLIsh LANguAge COMPeTeNCe You will be required to provide evidence of your English language proficiency if English is not your first language. Is English the language that you and your family speak at home? Please attach evidence of your English proficiency Test name If you are yet to take a test, please indicate when results will be available: Result Yes No

5. seCONDARy sChOOL/hIgh sChOOL/FOuNDATION sTuDIes Please name the school where you are at present, or were last enrolled. School Country Last year enrolled

What is the highest level of achievement you hold from a secondary/high school? Your highest achievement may be a New Zealand award such as NCEA Level 2, or you may have achieved an overseas qualification. Please specify: Are you completing the final year of a secondary/high school or foundation qualification? If yes, please indicate when the results will be available: Yes No

6. DistAncE stuDy Are you enrolling for Distance Learning papers in 2010? a) Examination Centre Please specify the major city nearest to your study address: b) Audioconference Venue If applicable, please indicate where you will be attending audioconferencing sessions: c) Consent to Release of Contact Details Distance students are encouraged to contact others enrolled in the same paper(s) for mutual support. Please indicate whether or not you consent to have your contact details included in class lists. CONSENT DO NOT CONSENT Yes (please complete this section) No (go to section 7)

7. MeThOD OF QuALIFyINg FOR ADMIssION TO The uNIveRsITy OF OTAgO On the basis of an overseas qualification: Please specify qualification: On the basis of a qualification gained in New Zealand NCEA Level 3: please specify year(s) Bursaries examinations: please specify year(s) Foundation Studies: please specify institution
Year gained

Year gained:

Other: please specify

Year gained

8. PRIOR ACTIvITy (this information is collected for statistical purposes only) Were you or will you be resident outside New Zealand at 1 October 2009? Yes No

If no, please indicate your main activity or occupation at 1 October 2009. 1. Secondary or high school student 2. Non-employed or beneficiary (excluding retired) 3. Wage or salary earner 4. Self-employed 5. University student 6. Polytechnic student 7. College of Education (teachers college) student 8. House person or retired 10. Private training establishment student

9. PRevIOus TeRTIARy/uNIveRsITy LeveL sTuDy If you have previously attended any tertiary institution, either in New Zealand or overseas, please specify your first year of enrolment. First Year of Enrolment at any Tertiary Institution If applicable, please indicate the last type of tertiary institution you attended. (Tick one circle only) Overseas university Overseas tertiary institution 2010 will be my
e.g. 1st, 5th

New Zealand university New Zealand polytechnic year of university study (including overseas).

New Zealand college of education New Zealand private training establishment

Please list all universities you have attended, years of your enrolment, and your ID number at each university. Name of University/College From To ID Number (if known)

Have you ever been suspended or excluded from any other New Zealand university? No Yes Name of university Year

Please specify any tertiary qualifications obtained. (Original or witnessed evidence must be attached if not already provided.) Qualification Name of Tertiary Institution

Are you sitting examinations this year? If yes, please indicate when results will be available Do you expect to complete your degree or diploma this year? Are you seeking credit at Otago for previous tertiary studies? 10. DePeNDANTs Do you plan to bring dependants with you? Yes No

Yes

No

Yes Yes

No No

11. ReseARCh exPeRIeNCe Complete this section only if you are applying for direct entry to a research/thesis programme. Are you applying for direct entry to a research/thesis only programme? Yes No If No, please go to section 12.

If Yes, please provide a curriculum vitae or personal statement which covers A to D of this section.

A. Research Proposal Please provide a research proposal including tentative thesis title (please attach a typed proposal). You must discuss your research proposal with the relevant academic department at Otago before submitting this application. Have you corresponded with an academic staff member about your proposal? If yes, please provide name: B. Publications Please list any publications including titles of theses submitted. C. Other Research Experience D. Academic Referees Please indicate the name, position, address (including phone, fax and email) of up to three referees the University may choose to consult.

12. DeCLARATION AND sIgNATuRe Please read the following declarations and sign below. Admission and Enrolment
I declare that all the information now submitted, or which I will later submit, in connection with my enrolment (whether on a physical form, entered electronically, or in any supporting documents) is correct and complete. I authorise the University of Otago to obtain official records from any educational institution that I have previously attended. I understand that the University reserves the right to vary or reverse any decision regarding admission or enrolment made on the basis of incorrect or incomplete information provided by me.

Privacy
I understand that information supplied in connection with my enrolment and study at the University may be used (a) by members of the Universitys academic and administrative staff for purposes relating to my enrolment and study, and also for such purposes by any other tertiary institution in New Zealand to which I may transfer and (b) for purposes external to the University when the information is in statistical form or when the University reasonably believes it is not to my disadvantage for such external use to occur. I acknowledge that, in accordance with the provisions of the Privacy Act 1993, disclosure of my information may be required or permitted in certain cases, including disclosure to Government agencies such as the New Zealand Police, Ministry of Education, Ministry of Justice, Ministry of Social Development, Accident Compensation Corporation, Inland Revenue Department and the Tertiary Education Commission. I understand that I have the right to see, and correct if necessary, information held about me.

Regulations
I do solemnly promise that I will faithfully obey the regulations of the University of Otago so far as they apply to me; and I hereby declare that I will have attained the age of sixteen years by 31 December 2009. Note: This declaration (which is required to be made by the virtue of the Universitys Admission and Enrolment Statute) confirms the binding nature of all regulations established by or under the authority of the University Council. Attention is particularly drawn to: The Code of Student Conduct (published in the University Calendar and at www.otago.ac.nz/study/regulations/discipline.html#codeofstudentconduct); and The Computer Regulations (published in the University Calendar and at www.otago.ac.nz/study/regulations/computer).

Computer Use
I understand that the University may monitor data entered or changed by users and reserves the right to take disciplinary action in cases involving false, misleading, or offensive data, and that the University accepts no liability for consequences arising from the divulging of usernames or passwords to others.

Fees and Course Materials

I accept responsibility for the payment of all fees (including tuition fees) charged by the University. Should I default on payment of all or part of those fees, I agree to pay all costs relating to the collection of the outstanding debt. If my fees are paid by a Government Student Loan through the Ministry of Social Development (StudyLink) and I become eligible for a refund of all or part of those fees, I authorise the University to pay the refund directly back to StudyLink to be credited against my student loan balance. I undertake to return course materials supplied to me in connection with any paper from which I subsequently withdraw, if that is a departmental requirement, or to accept liability for payment for the material.

Copyright
I understand that I must observe the Copyright Act 1994 in relation to any teaching materials supplied to me in the course of study at the University and that I may not make unauthorised sound recordings of lectures or audioconferences.

Intellectual Property Rights (for thesis students)

I undertake to abide by the Universitys Policy for Intellectual Property Rights of Graduate Research Students.

Immigration (for students who are not New Zealand citizens)

I authorise the University and Immigration New Zealand and the Department of Labour to supply information about me to each other if it is considered to be relevant to my immigration status and/or my enrolment status.

Course of Study
I accept responsibility for satisfying myself as to the suitability of my own course of study. I understand that my course must comply with programme regulations and that I must not undertake a course involving unresolved timetable clashes. I acknowledge that in finalising my course and in making any subsequent changes I must abide by requirements of Advisers of Studies.

Applicants Signature

Amendments to Course
If the course for which I have sought enrolment requires amendment (because of my failure in any examinations or assessment, or because of the regulations for the programme concerned) I agree that the University may make any necessary changes to my course. I understand that I will be informed in writing of any such changes or will have the opportunity to revise my course in consultation with relevant Advisers of Studies.

Date

For immediate application purposes a scanned or faxed copy of this form can be accepted. However, a form with an original signature of the applicant must be airmailed or couriered to the International Office as early as possible.

CheCkLIsT FOR sTuDeNTs Have you included or completed the following? ACADeMIC DOCuMeNTATION High School or Foundation Studies Original or witnessed copies of your High School or Foundation Study results* or Forecast or preliminary results on the official letterhead of your school Previous Tertiary Studies Original or witnessed copies of all previous tertiary study results* Research Proposal Curriculum vitae for research study EDUCATION CREDENTIALS EVALUATION (ECE) My qualifications are from a country requiring ECE evaluation. I have sent my records to ECE for a course-by-course evaluation Please refer to www.otago.ac.nz/international for further information. eNgLIsh DOCuMeNTATION Original copy of English language results CITIZeNshIP sTATus Passport details Birth certificate The University requires documentary evidence of your citizenship and the correct form of your name. This can be provided by supplying: a) a witnessed copy of the front page of your passport showing personal details including name and date of birth; or b) an original or witnessed copy of your birth certificate. Documents must be in English or be accompanied by a certified English translation. Note: Your application form cannot be processed without evidence of your name and citizenship status.

*PLeAse NOTe Please attach witnessed (certified/notarised) copies of all academic transcripts and award certificates, including results of studies currently being undertaken. A key/guide to the grading system must also be included. Documents not in English must be accompanied by witnessed English language translations. Witnessed copies must: 1) be stamped with an official seal or stamp; 2) bear the printed name, signature and position of the person certifying the copy; and 3) have the date when the copy was certified. Documents may be witnessed by a Justice of the Peace, Notary Public, Court Official or Solicitor. Please do not supply your application and documentation in bound form or in folders.

PLEASE RETURN THIS FORM WITH ORIGINAL SIGNATURE TO: Mailing Address International Office, University of Otago PO Box 56, Dunedin 9054, New Zealand Tel 64 3 479 8344, Fax 64 3 479 8367 Email international.admissions@otago.ac.nz Website www.otago.ac.nz/international Courier Address International Office, Clocktower Building University of Otago, Leith Street, Dunedin, New Zealand

FOR OFFICe use ONLy Evidence of Name Evidence of Date of Birth Evidence of Citizenship/Residency Admission to University Course Checked by Original Documents Returned: Type: Date: Signed: Other